Referral to Vocational Rehabilitation
                      Vocational Rehabilitation (VR) is here to help individuals with disabilities prepare for, advance in, or retain employment.
	                                                                                                                                   Date of Referral                   

Name of Individual (Please print)
                                                                           	Date of Birth
     	Social Security Number
     	
Address (Home)
     	City
     	State
   	Zip
     	
Address (Mailing)
     	City
     	State
   	Zip
     	
Telephone Number     Home       Cell
     	Additional Contact Name
     	
What is the best method of contact? (Select one)
          E-mail      Mail     
          Phone      Other (specify)                 	Additional Contact Phone Number
     	
	Additional Contact E-mail
     	
Can VR leave a message at the number listed above?                     Yes          No	Gender         Male      Female
                      Does not wish to disclose or self-identify	
E-mail Address
     	Have you ever received services from VR?         Yes            No	
Marital Status            Divorced       Married    
 Never Married     Separated     Widowed	Education Level
     	
Ethnicity        
            Hispanic or Latino
            Not Hispanic or Latino
            Does not wish to disclose or self-identify	Race (Check all that apply)      
  American Indian/Alaska Native           Asian        
  Black or African American                   White
  Native Hawaiian or Other Pacific Islander    
  Does not wish to disclose or self-identify	
Accommodations   
           Do you require an Interpreter?                        Yes, ASL              Yes other, specify language:      
           Do you require an assistive listening device?                                   Yes
           Do you require translated documents?                                             Yes
           Do you require any other accommodations for your impairment?    Yes   If so, please explain:      	
What impairment prevents you from working?      	
How can VR help you become employed?      
     	
How did you hear about us?       	
Agency/Vendor/School:                                 	Contact Person:      	Phone #:      	
Please complete this page then mail or turn in the referral to the nearest VR office.  For a list of offices, go to www.rehabworks.org and then click on “Contact Us” and then select “Directory of Local VR Offices and Vendors”; or you may call our toll free number
1-(800)-451-4327 for more information.
For Office Use Only	Received Date :                    	Outcome of Referral	
	     Phone     Mail      In Person     Fax	 Completed Application	
	Contact Date:                             Contacted by:                                                   	 Decided not to apply	
	             Phone     Letter    In Person     	 Missed Orientation	
	Orientation Scheduled:    Group        Individual       Date:                                                   	 Other                               	
	Additional Notes:                                                                                                                                                                       	
local street address line 1    city, state, zip    phone    Fax: fax number